The 3-month follow-up assessment for the early intervention group
followed the completion of the 10-week session of CBITS intervention, and
for the delayed intervention group it was without the CBITS intervention.
The 6-month follow-up assessment for the early intervention group was approximately
3 months following the completion of the CBITS intervention, and for the delayed
intervention group it occurred immediately following the completion of the
10-week session CBITS intervention. CBITS indicates Cognitive-Behavioral Intervention
for Trauma in Schools.

CBITS indicates Cognitive-Behavioral Intervention for Trauma in Schools;
CDI, Child Depression Inventory; CI, confidence interval; CPSS, Child PTSD
Symptom Scale; and PTSD, posttraumatic stress disorder. The delayed intervention
comparison group did not undergo CBITS during the first 3 months of the study.
At the 3-month assessment, students in the early intervention group had significantly
lower self-reported symptoms of PTSD than did students in the delayed intervention
group. At 6 months, after the delayed intervention group completed the CBITS
intervention, a difference no longer existed between the groups. At 3 months,
scores for self-reported symptoms of depression were lower than in those of
the delayed intervention group. At 6 months, this significant difference no
longer existed. Error bars indicate 95% CIs.

Parents of students in the early intervention group reported significantly
less psychosocial dysfunction at 3 months compared with parents of students
in the delayed intervention group. At 6 months, after the delayed intervention
group completed the CBITS intervention, the parents of students in the early
intervention and delayed intervention group had similar ratings of child psychosocial
dysfunction. Error bars indicate 95% confidence intervals (CIs).

Figure 4. Teacher Report of Students Using
the Teacher-Child Rating Scale for Classroom Acting Out, Shyness/Anxiousness,
and Learning Problem Subscales

Teachers did not report a significant difference in classroom behavior
between students in the early intervention group and delayed intervention
group. At 3 months, the adjusted mean difference was −1.0 on the acting
out behavior scale, 0.1 on the shyness/anxiousness scale, and −1.1 on
the learning problems scale. At 6 months, the adjusted mean difference was
−0.9 on the acting out behavior scale, −0.9 on the shyness/anxiety
scale, and −1.9 on the learning problems scale. Error bars indicate
95% confidence intervals.

Table 1. Clinical and Demographic Characteristics
of Participants at Baseline

Youth Violence: A Report of the Surgeon General-Executive Summary . Rockville, Md: US Dept of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Injury Prevention and
Control; Substance Abuse and Mental Health Services Administration, Center
for Mental Health Service; and National Institutes of Health, National Institute
of Mental Health; 2001.

Cohen JA. American Academy of Child Adolescent Psychiatry Work Group on Quality
Issues: practice parameters for the assessment and treatment of children and
adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry Special Issue: Practice Parameters.1998;37(10 suppl):4S-26S.

Context No randomized controlled studies have been conducted to date on the
effectiveness of psychological interventions for children with symptoms of
posttraumatic stress disorder (PTSD) that has resulted from personally witnessing
or being personally exposed to violence.

Objective To evaluate the effectiveness of a collaboratively designed school-based
intervention for reducing children's symptoms of PTSD and depression that
has resulted from exposure to violence.

Setting and Participants Sixth-grade students at 2 large middle schools in Los Angeles who reported
exposure to violence and had clinical levels of symptoms of PTSD.

Intervention Students were randomly assigned to a 10-session standardized cognitive-behavioral
therapy (the Cognitive-Behavioral Intervention for Trauma in Schools) early
intervention group (n = 61) or to a wait-list delayed intervention comparison
group (n = 65) conducted by trained school mental health clinicians.

Results Compared with the wait-list delayed intervention group (no intervention),
after 3 months of intervention students who were randomly assigned to the
early intervention group had significantly lower scores on symptoms of PTSD
(8.9 vs 15.5, adjusted mean difference, − 7.0; 95% confidence interval
[CI], − 10.8 to − 3.2), depression (9.4 vs 12.7, adjusted mean
difference, − 3.4; 95% CI, − 6.5 to − 0.4), and psychosocial
dysfunction (12.5 vs 16.5, adjusted mean difference, − 6.4; 95% CI,
–10.4 to –2.3). Adjusted mean differences between the 2 groups
at 3 months did not show significant differences for teacher-reported classroom
problems in acting out (−1.0; 95% CI, –2.5 to 0.5), shyness/anxiousness
(0.1; 95% CI, –1.5 to 1.7), and learning (−1.1, 95% CI, –2.9
to 0.8). At 6 months, after both groups had received the intervention, the
differences between the 2 groups were not significantly different for symptoms
of PTSD and depression; showed similar ratings for psychosocial function;
and teachers did not report significant differences in classroom behaviors.

Conclusion A standardized 10-session cognitive-behavioral group intervention can
significantly decrease symptoms of PTSD and depression in students who are
exposed to violence and can be effectively delivered on school campuses by
trained school-based mental health clinicians.

In the last decade, there has been heightened awareness of the extent
to which children personally witness or experience violence.1- 3 Public
health officials have responded by identifying violence as one of the most
significant US public health issues.4- 6 Large
numbers of US children experience such violence, and an even greater number
may experience symptoms of distress after personally witnessing violence directed
at others.2,7- 9 For
many children, personally experiencing or directly witnessing multiple incidents
of violence is the norm.3,10,11 Violence
affects all racial, ethnic, and socioeconomic groups, but its burden falls
disproportionately on urban,5,12 poor,
and minority populations.13,14

Several studies have found that the majority of children exposed to
violence, defined as personally witnessing or directly experiencing a violent
event, display symptoms of posttraumatic stress disorder (PTSD),15,16 and
a substantial minority develop clinically significant PTSD.17- 19 However,
the harmful effects of violence extend beyond symptoms of PTSD. Exposure to
violence is associated with depression20 and
behavioral problems.2,9,21 In
addition, children exposed to violence are more likely to have poorer school
performance,22- 24 decreased
IQ and reading ability,25 lower grade-point
average, and more days of school absence,22 even
if they do not develop PTSD. Exposure to violence also may interfere with
the important developmental milestones of childhood and adolescence.26

These wide-ranging negative sequelae of violence have stimulated calls
for interventions that address the needs of children who are experiencing
a range of symptoms after witnessing or experiencing violence.27 Yet
despite the enormous public health significance of this violence, no randomized
controlled trials have been conducted to date of interventions for these children
who have been exposed to violence and have experienced symptoms.

For several years, Los Angeles Unified School District (LAUSD) school
mental health clinicians and clinician-researchers from local research institutions
have collaborated to document the magnitude of exposure to violence among
LAUSD students10 and to develop, implement,
and evaluate a standardized intervention for students experiencing symptoms
after exposure to violence.28,29 Based
on our previous research, we conducted a randomized controlled trial to test
the effectiveness of a cognitive-behavioral therapy (CBT) group intervention
to reduce symptoms of PTSD and depression and to improve psychosocial functioning
and classroom behavior in students in the general school population of 2 large
urban middle schools.

METHODS

Participants

The evaluation was conducted during the 2001-2002 academic year at 2
middle schools in East Los Angeles, a socioeconomically disadvantaged, primarily
Latino area of Los Angeles. After parents agreed to have their children participate
and children agreed to be screened, trained LAUSD school mental health clinicians
administered a self-report questionnaire regarding exposure to violence and
symptoms of PTSD to 769 English-speaking sixth-grade students during class
time, in groups of 25 to 30 students. Clinicians read the questions aloud
to the students, who sat apart from one another to ensure privacy. Students
were screened for exposure to violence using a modified version of the 34-item
Life Events Scale.1 They were asked about multiple
types of violence (slapping, hitting, punching; beatings; knife attacks; and
shootings) and reported separately how frequently they had experienced directly
or had witnessed personally each type of violence. Several questions that
asked specifically about violence at home were removed at the request of school
personnel. Students were instructed not to include media violence and violence
that they had only heard about.

Students were eligible to participate in the program if they (1) had
substantial exposure to violence, defined as being the victim or witness of
violence involving a knife or gun or having a Life Events Scale summed score
greater than 6, consistent with exposure to 3 or more violent events; (2)
had symptoms of PTSD in the clinical range, assessed using the 17-item Child
PTSD Symptom Scale (CPSS)30; (3) had symptoms
of PTSD related to exposure to violence that they were willing to discuss
in a group as determined by their school-based mental health clinician; and
(4) did not appear too disruptive to participate in a group therapy intervention
session in the opinion of their school-based mental health clinician. One
hundred fifty-nine students met the inclusion criteria and were offered participation
in the program; written informed consent was obtained from parents, and assents
were obtained from students. Thirty-three students did not participate; 28
parents did not give consent and 5 students did not agree to participate.

One hundred twenty-six students chose to participate and completed the
baseline assessments. One hundred seventeen students (93%) completed the 3-month
follow-up assessments; 113 (90%) completed both the 3-month and 6-month follow-up
assessments. The study was conducted in compliance with the LAUSD's research
review committee and the institutional review boards of RAND and UCLA.

Study Protocol

After the school mental health clinician obtained parent consent and
student assent to participate in the program, a central office was used to
randomly assign students to an early intervention group (n = 61) or to a wait-list
delayed intervention group (n = 65) using random numbers generated by the
clinician-researchers, using Microsoft Excel 2001.31 Because
school officials preferred to provide the intervention program to all students
in the same academic year, students assigned to the wait-list delayed intervention
comparison group participated in the program 3 months following screening
of the early intervention group and all the participants had completed the
3-month follow-up assessment. The flow diagram (Figure 1) shows the sampling and assignment of students to the early
intervention and delayed intervention groups, as well as the timing of the
assessments and the intervention for both groups.

Intervention

The intervention was a 10-session CBT group called the Cognitive-Behavioral
Intervention for Trauma in Schools (CBITS),32 which
was designed for use in an inner-city school mental health clinic with a multicultural
population (Box). The CBITS
intervention incorporates CBT skills in a group format (5-8 students per group)
to address symptoms of PTSD, anxiety, and depression related to exposure to
violence. Generally, in each session a new set of techniques was introduced
by a mixture of didactic presentation, age-appropriate examples and games
to solidify concepts, and individual work on worksheets during and between
sessions. The techniques taught to the students were similar to those used
in other CBT groups for individuals with PTSD.33 The
CBITS intervention emphasizes applying techniques learned in the program to
the child's own problems. Homework assignments were developed collaboratively
between the student and the clinician in each session and were reviewed at
the beginning of the next session.

The CBITS intervention was implemented on a continuous basis from the
late autumn through the spring of the 2001-2002 academic year by 2 full-time
and 1 part-time psychiatric social workers from the LAUSD Mental Health Services
Unit. The groups most often met once a week. Students were excused from 1
class period to attend the group sessions, which lasted 1 class period. Clinicians
consulted with school administrators and liaison staff to determine when to
conduct the group sessions. The sessions often were offered at different times
each week so that they could be conducted during study halls and other nonacademic
periods when possible, and to minimize the number of times a student would
miss the same academic class.

The CBITS intervention previously had been pilot tested for feasibility
and acceptability; a pilot study using the CBITS intervention manual and format
is reported elsewhere.29 School clinicians
received 2 days of training for application of the intervention and weekly
group supervision from the clinician investigators (B.D.S., L.H.J., S.H.K.).
The school clinicians followed a treatment manual to ensure that the application
of the intervention was standardized across clinicians. However, they had
some flexibility to meet the specific needs of the students in the group.

Assessment of Intervention Integrity

We examined the integrity of the intervention as delivered by the clinicians
compared with the CBITS manual by having an objective clinician rater listen
to randomly selected audiotapes of sessions and assess both the extent of
completion of the session material and the overall quality of therapy provided.
Using a scale developed for this intervention, completion of required intervention
elements, including at least cursory coverage of the topic, varied from 67%
to 100% across sessions, with a mean completion rate of 96%. On 7 items assessing
quality, quality of sessions was moderate to high across sessions.

Outcomes Examined

Data from students, parents, and teachers were collected at baseline,
3 months, and 6 months (Figure 1).
To assess students' symptoms of PTSD, we used the CPSS,30 a
17-item child self-report measure (range, 0-51 points), which has been shown
to have good convergent and discriminant validity, high reliability,30 and high internal consistency29 in
school-aged children. Students rated how often they were bothered by each
symptom in the past month on a scale from 0 (not at all) to 3 (almost always).
For program eligibility, symptoms of PTSD in the clinical range were defined
as a sum score of 14 or more, consistent with moderate clinical levels of
symptoms of PTSD.

Students' symptoms of depression in the past 2 weeks were assessed using
a 26-item Child Depression Inventory (CDI).34 The
CDI (range, 0-52 points) assesses children's cognitive, affective, and behavioral
symptoms of depression, and has good test-retest reliability and validity.35- 37 A single item that
assessed suicidality was removed at the request of school personnel.

Child psychosocial dysfunction was assessed using the 35-item Pediatric
Symptom Checklist (PSC) (range, 0-70 points),38- 41 in
which the student's parent rated the frequency of the student's emotional
and behavioral problems on a scale from 0 (never) to 2 (often).

Classroom behavior was assessed by having the student's teacher complete
the 6-item Teacher-Child Rating Scale for shyness/anxiousness, learning problems,
and acting out behavior problem subscales (range of subscales, 6-30 points).42 The Teacher-Child Rating Scale, in which teachers
rate how much of a problem each behavior has been on a scale from 1 (not a
problem) to 5 (very serious problem), previously has been used to assess classroom
behavior problems in comparable students.43

Analyses

We compared the early intervention and delayed intervention group clinical
and demographic characteristics at baseline. To assess the effectiveness of
the intervention, we used linear regression to estimate the mean difference
in outcome scores between the 2 intervention groups at 3 months and at 6 months,
adjusted for scores at baseline. Effect sizes were calculated to assess the
magnitude of intervention effects. These were calculated as the ratio of the
estimated treatment effect (early intervention score minus delayed intervention
score at follow-up, after controlling for baseline scores) to the pooled SD
at baseline.44 All analyses were performed
with Stata version 7.0.45

RESULTS

Baseline Characteristics

The enrolled sample of 126 students had substantial levels of exposure
to violence and symptoms of PTSD (Table
1). The mean number of violent events in the previous year experienced
by the students was 2.8 and the mean number witnessed by the students was
5.9. The mean percentage of students who reported experiencing or witnessing
violence involving a knife or gun was 76%. The mean CPSS score was 24.0, indicating
moderate to severe levels of symptoms of PTSD. The mean CDI score was 17.2.
The early intervention and delayed intervention groups did not show significant
differences in baseline values.

At the 3-month assessment, students in the early intervention group
had significantly lower self-reported symptoms of PTSD than did students in
the delayed intervention group (8.9 vs 15.5) (Table 2). The mean difference between the groups, adjusted for baseline
scale scores, was –7.0 (95% CI, − 10.8 to − 3.2) (Table 2), an effect size of 1.08 SDs. This
result indicates that 86% of the students who underwent CBITS intervention
reported lower scores of symptoms of PTSD at 3 months than what would have
been expected if they had not undergone intervention.44 At
6 months, after the delayed intervention group completed the CBITS intervention,
a difference no longer existed between the groups, with an adjusted mean difference
of 0.3 (8.2 vs 7.2; 95% CI, −3.4 to 3.9) (Table 2 and Figure 2).

Scores for self-reported symptoms of depression also were lower in the
early intervention group at 3 months than in those of the delayed intervention
group, with an adjusted mean difference of –3.4 (9.4 vs 12.7; 95% CI,
− 6.5 to − 0.4), an effect size of 0.45 SDs. This indicates that
67% of the students who underwent CBITS intervention reported lower scores
of symptoms of depression at 3 months than what would have been expected if
they had not undergone intervention. At 6 months, after the delayed intervention
group completed the CBITS intervention, a significant difference no longer
existed in the scores for symptoms of depression between the 2 groups, with
an adjusted mean difference of –0.8 (9.0 vs 10.0; 95% CI, − 4.1
to 2.5) (Table 2 and Figure 2).

Parents of students in the early intervention group reported significantly
less psychosocial dysfunction at 3 months compared with parents of students
in the delayed intervention group (12.5 vs 16.5) (Table 2). The adjusted mean difference was –6.4 (95% CI, −
10.4 to − 2.3), an effect size of 0.77 SDs. This indicates that 78%
of the parents of students who underwent CBITS intervention had less psychosocial
dysfunction at 3 months than what would have been expected if they had not
undergone intervention. At 6 months, after the delayed intervention group
completed the CBITS intervention, the parents of students in the early intervention
and delayed intervention group had similar ratings of child psychosocial dysfunction,
with an adjusted mean difference of –1.9 (9.4 vs 8.9; 95% CI, −
5.8 to 2.1) (Figure 3).

Teachers did not report a significant difference in classroom behavior
between students in the early intervention group and delayed intervention
group (Table 2). At 3 months,
the adjusted mean difference was –1.0 on the acting out behavior scale,
0.1 on the shyness/anxiousness scale, and −1.1 on the learning problems
scale. At 6 months, the adjusted mean difference was −0.9 on the acting
out behavior scale (Table 2 and Figure 4), − 0.9 on the shyness/anxiousness
scale, and − 1.9 on the learning problems scale (Figure 4).

COMMENT

This is the first study to date to use a randomized controlled trial
to evaluate the effectiveness of an intervention for children with substantial
levels of symptoms of PTSD who have been exposed to a wide range of violent
events. Complementing the work of other researchers who have developed interventions
for children affected by child sexual abuse,46- 48 natural
disasters,49,50 and single-incident
traumas,33 this study takes an important step
toward developing and empirically evaluating a standardized intervention for
children experiencing symptoms following exposure to violence.

Students who received this brief standardized intervention, delivered
by school mental health clinicians on school campuses, had significantly fewer
self-reported symptoms of PTSD and depression, and fewer reports of psychosocial
dysfunction by parents at the 3-month assessment, than did students who were
randomly assigned to a delayed intervention comparison group. The delayed
intervention group experienced a smaller decrease in symptoms of PTSD and
depression while on a waiting list to receive the intervention; when they
received the intervention, they too showed a significant reduction in symptoms
of PTSD and depression. At 6 months, after both groups had received the intervention,
students in both groups had similar levels of symptoms of PTSD, depression,
and psychosocial dysfunction.

In our prior research, we used a quasi-randomized design to examine
the effectiveness of the CBITS intervention in a recent immigrant population
of students in the third through eighth grades in a number of different schools.29 In this study, we were able to evaluate the effectiveness
of the intervention in a fully randomized controlled trial of sixth graders
in the general school population, and we were able to monitor the fidelity
of the intervention. The results of our prior study in recent immigrant students,
combined with results of this study, demonstrate that a carefully implemented
community-based intervention can significantly reduce symptoms of PTSD in
the short term.

During the process of engaging school stakeholders as collaborative
research partners, it became clear that we could have relatively few exclusion
criteria for the intervention program.28 This
had the salutary effect of significantly increasing the generalizability of
the study—for example, by not excluding students with comorbid disorders
unless the student was deemed by the clinician to be too disruptive to participate
in group treatment. Many clinicians have called for such increased generalizability
as efforts are made to develop and evaluate interventions in community settings.51,52

In recent years, there have been increasing calls for developing effective
mental health interventions that can be delivered within the constraints of
community settings in which children and adolescents are commonly seen.53,54 However, such interventions remain
quite rare, and a recent review of school-based interventions noted the paucity
of research in evaluating programs that address symptoms of PTSD,55 despite the high prevalence of symptoms of PTSD in
school-aged children.10,16,19 Recognizing
the need for such programs and the important role that could be played by
schools, the Report of the Surgeon General's Conference
on Children's Mental Health: A National Action Agenda called for an
increase in schools' capacity to meet children's emotional needs.56 Children from poor and minority backgrounds, those
populations who are at highest risk for exposure to violence, are the same
populations whose mental health needs are least likely to be met by the current
health care system.57 Interventions delivered
in schools have the potential for overcoming many of the key barriers to accessing
the health care system faced by these populations.58

For many children, schools have long been the de facto provider of mental
health services.59 School counselors, psychologists,
and social workers traditionally have provided many of these services60; school-based health clinics, which often provide
a range of health care and mental health services to students,61,62 are
another rapidly growing alternative.63

A critical aspect of this program was the collaborative partnership
between school personnel and clinician-researchers. Our frequent consultations
with school staff about implementation issues and our efforts to educate teachers
and administrators about how violence affects children helped to make the
program acceptable and relevant to schools. Close work with school personnel
during CBITS development also ensured that clinicians already working in schools
could implement the program. The study results demonstrate the feasibility
of our approach; school-based clinicians delivered the intervention with integrity
and high quality. However, putting such a program in place does require shifting
some of clinicians' day-to-day responsibilities. More time would be spent
providing standard manual-based treatments for specific psychiatric problems
and less time providing general supportive counseling. In addition, our program
increased detection of mental health symptoms related to violence through
general screening of students instead of relying on referrals from school
staff. Such screening is critical since children experiencing disorders such
as depression or PTSD are unlikely to be recognized and referred for treatment.64,65

The magnitude of the effect of this school-based intervention on child-
and parent-reported outcomes is comparable with that of child psychotherapy
intervention trials for other disorders that have been conducted in more homogeneous
populations66,67 and are considered
"moderate" (for depression) to "very large" (for symptoms of PTSD).44 A national study reported that important risk factors
for child mental health problems, such as poverty and single-parent status,
were associated with PSC scores that were on average 4 points higher than
scores of other children39; less than the 6-point
improvement reported by parents in our intervention group.

Teachers did not report significant improvements in the classroom behavior
of the early intervention group compared with the delayed intervention group
at either 3 months or 6 months. Disagreement about symptoms or diagnosis in
children as rated by children, teachers, and parents is common in studies
using multiple informants, even those that use the same measure,68 and
student's classroom behavior is affected by many factors, not just the child's
mental health. It may be that the improvement in symptoms in the early intervention
group did not translate into improved classroom behavior. Another explanation
is that there may be a time lag before children's symptomatic improvement
translates into improved classroom behavior. This possibility may explain
our finding that adjusted mean differences between the groups for the teacher-reported
measures were approximately the same size or slightly greater at 6 months
than 3 months, while the adjusted mean differences for the child and parent
measures were much smaller at 6 months than 3 months. Teachers also may be
more attuned to disruptive behaviors in their classroom and less aware of
symptoms of anxiety and depression that a child may experience silently. Alternatively,
the Teacher-Child Rating Scale subscales we used may not be as sensitive to
clinical improvement as are the child and parent measures.

The discrepancies between the teachers' assessment and those of other
respondents must be addressed in future research of school-based mental health
programs, as must the impact of such interventions on other outcomes such
as grades. The mission of schools continues to be education, not treatment.
Widespread acceptance of school mental health programs requires more information
about the impact of such programs on school outcomes, as well as data about
whether such programs are cost-effective and can be implemented in ways that
allow reimbursement for providing services.

All students received the intervention within a single academic year.
As a result, we only examined the short-term effectiveness of the program.
The intervention is designed to increase resilience and build coping skills,
so it is possible that the intervention will have a lasting effect on the
students as they face new stressors and traumatic events. At the time of screening,
the students in the study had a high degree of chronic exposure to violence.
It is promising that students who were randomly assigned to the early intervention
group maintained improvement at the 6-month assessment. However, we have no
information about exposure to new violence during this period. Such information
and a longer follow-up period are needed to assess the intervention's long-term
effectiveness and to determine if the program builds resilience as these vulnerable
children face traumatic events in the future. This information also would
tell us more about whether booster sessions or other follow-up might be necessary
for some children. Follow-up over multiple academic years also is needed to
directly examine the program's effect on school grades and other school outcomes.

The CBITS intervention was not compared with a control condition such
as general supportive therapy, but rather with a wait-list delayed intervention.
As a consequence, none of the informants (students, parents, or teachers)
were blinded to the treatment condition. It is possible that the lack of blinding
may have contaminated either the intervention or assessments. School staff
and parents may have provided more attention and support to students who were
eligible for the program while they were on a wait-list; alternatively, respondents
may have been more likely to report improvement in symptoms for those students
for whom they knew had received the intervention. Using blinded evaluators
is an important step for the future, to provide an objective rating of outcomes.

Future research comparing CBITS with an alternative intervention, such
as generic support and attention, also would be an important next step, in
part to reduce biases among respondents, and also to control for the attention
that children receive as being part of the program. However, such designs
often are difficult to implement in school settings, where there is a push
to provide the same program to all students, and randomization to a placebo
can be seen as insensitive to the needs of students and families.69 Further research also is needed to determine if our
findings would be replicated in nonurban and non-Latino populations, and to
examine the intervention's effectiveness in alternative settings treating
large numbers of children, such as pediatric clinics, adolescent medicine
clinics, and community mental health centers.

Violence remains a serious public health problem, the psychological
consequences of which affect children across the country. Yet clinicians working
with such children often have lacked evidence-based treatments. This intervention,
designed in collaboration with the school district in which it was implemented
and delivered by school clinicians, may be a promising model for community-based
programs for children who experience or witness violence, who frequently face
multiple barriers in accessing mental health services.

Youth Violence: A Report of the Surgeon General-Executive Summary . Rockville, Md: US Dept of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Injury Prevention and
Control; Substance Abuse and Mental Health Services Administration, Center
for Mental Health Service; and National Institutes of Health, National Institute
of Mental Health; 2001.

Cohen JA. American Academy of Child Adolescent Psychiatry Work Group on Quality
Issues: practice parameters for the assessment and treatment of children and
adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry Special Issue: Practice Parameters.1998;37(10 suppl):4S-26S.